Esophageal cancer surgery: Difference between revisions
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==Overview== | ==Overview== | ||
The predominant therapy for esophageal cancer is surgical resection by esophagectomy. Adjunctive chemotherapy and radiation may be required. | The predominant therapy for esophageal cancer is surgical resection by esophagectomy. Adjunctive chemotherapy and radiation may be required in more advanced cases of esophageal cancer. | ||
==Esophagectomy== | ==Esophagectomy== | ||
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*The procedure shortens the distance between the pharynx and the stomach. | *The procedure shortens the distance between the pharynx and the stomach. | ||
*The stomach, or some other part of the gastrointestinal tract, such as the colon, is brought up into the chest cavity where it is interposed. | *The stomach, or some other part of the gastrointestinal tract, such as the colon, is brought up into the chest cavity where it is interposed. | ||
* | *There are two surgical approaches: | ||
*One approach promotes the transhiatal esophagectomy with anastomosis of the [[stomach]] to the cervical [[esophagus]] technique. | **One approach promotes the transhiatal esophagectomy with anastomosis of the [[stomach]] to the cervical [[esophagus]] technique. | ||
*A second approach advocates abdominal mobilization of the [[stomach]] and transthoracic excision of the esophagus with anastomosis of the [[stomach]] to the upper thoracic esophagus or the cervical esophagus. | **A second approach advocates abdominal mobilization of the [[stomach]] and transthoracic excision of the esophagus with anastomosis of the [[stomach]] to the upper thoracic esophagus or the cervical esophagus. | ||
==Surgical Considerations== | ==Surgical Considerations== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]
Overview
The predominant therapy for esophageal cancer is surgical resection by esophagectomy. Adjunctive chemotherapy and radiation may be required in more advanced cases of esophageal cancer.
Esophagectomy
- Removing a segment of the esophagus is called an esophagectomy.[1][2][3]
- The disease must be localised in order for it to be operable.
- If a tumor is particularly large but still localised, it may be shrunk down first using chemotherapy and/or radiotherapy until the tumor becomes of a size that is operable.
- The procedure shortens the distance between the pharynx and the stomach.
- The stomach, or some other part of the gastrointestinal tract, such as the colon, is brought up into the chest cavity where it is interposed.
- There are two surgical approaches:
- One approach promotes the transhiatal esophagectomy with anastomosis of the stomach to the cervical esophagus technique.
- A second approach advocates abdominal mobilization of the stomach and transthoracic excision of the esophagus with anastomosis of the stomach to the upper thoracic esophagus or the cervical esophagus.
Surgical Considerations
- Patients with resectable tumors account for 20-30% of cases with esophageal cancer.[2][3]
- In patients with adenocarcinoma, surgery is recommended even if there is a good response with chemotherapy.
- This is because surgery achieves higher rates of local control and less need for palliative maneuvers later on.
- Patients should undergo surgery after having completed 4 to 6 weeks of chemotherapy or chemoradiotherapy.
- Unless, the patient is able to achieve cure without surgery or is unfit for surgery.
Indications
- The following are candidates for first line therapy with esophagectomy:
- T1N0M0 lesions
- T2N0M0 lesions
- The patients with the following are candidates for esophagectomy following neoadjuvant chemotherapy or chemoradiotherapy:
- Thoracic esophageal or esophagogastric junction tumors and full-thickness (T3) involvement of the esophagus with/without nodal disease
- T4a disease with invasion of local structures (pericardium, pleura, and/or diaphragm only) that can be resected en bloc, and who are without evidence of metastatic disease to other organ
Contraindications
- Advanced age
- Associated with greater morbidity following esophagectomy
- Comorbid illness
- Obesity can lead to postoperative complications such as cardiorespiratory complications, anastomotic leakage, and wound infection
Indications for unresectability
- The presence of metastatic disease:
- Such as peritoneal, lung, bone, adrenal, brain, or liver metastases, or extraregional lymph node spread
Surgery
Stage 0 Esophageal Cancer
Stage 0 squamous esophageal cancer is rarely seen in the United States, but surgery has been used for this stage of cancer[4]
Stage I Esophageal Cancer
Standard treatment options:
- Chemoradiation with subsequent surgery
- Surgery
Stage II Esophageal Cancer
Standard treatment options:
- Chemoradiation with subsequent surgery
- Chemoradiation alone
- Surgery alone
Stage III Esophageal Cancer
Standard treatment options:
- Chemoradiation with subsequent surgery
- Chemoradiation alone
Stage IV Esophageal Cancer
At diagnosis, approximately 50% of patients with esophageal cancer will have metastatic disease and will be candidates for palliative therapy.
Standard treatment options:
- Chemoradiation with subsequent surgery (for patients with stage IVA disease)
- Endoscopic-placed stents to provide palliation of dysphagia
- Radiation therapy with or without intraluminal intubation and dilation
- Intraluminal brachytherapy to provide palliation of dysphagia
- Nd:YAG endoluminal tumor destruction or electrocoagulation
- Chemotherapy has provided partial responses for patients with metastatic distal esophageal adenocarcinoma[5]
Stenting
- If the patient cannot swallow at all, a stent may be inserted to keep the esophagus patent.
- Stents may also assist in occluding fistulas.
- A nasogastric tube may be necessary to continue feeding while treatment for the tumor is given, and some patients require a gastrostomy (feeding hole in the skin that gives direct access to the stomach).
- Nasogastric tube and gastrostomy are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for aspiration pneumonia.
Laser therapy
- Laser therapy is described as the use of a high intensity beam of light to destroy malignant cells; it affects only the area it is focused on whilst unharming the healthy cells.[6][7]
- This is done when tumors are inoperable because of their size, location and/or spread.
- Sometimes, the aim is palliation, so that the patient may have some of the symptoms of dysphagia and pain relieved. [
- [Photodynamic therapy]] (PDT), a type of laser therapy, involves the use of drugs that are absorbed by cancer cells; when exposed to a particular wave length of light, the drugs become active and destroy the tumor cells.
Radiotherapy
- Radiotherapy is given before, during or after chemotherapy or surgery, and sometimes on its own to control symptoms.[8][9]
- In patients with localized disease but contraindications to surgery, "radical radiotherapy" may be used with curative intent.
References
- ↑ Wang HW, Chu PY, Kuo KT, Yang CH, Chang SY, Hsu WH, Wang LS (2006). "A reappraisal of surgical management for squamous cell carcinoma in the pharyngoesophageal junction". J Surg Oncol. 93 (6): 468–76. doi:10.1002/jso.20472. PMID 16615159.
- ↑ 2.0 2.1 Triboulet JP, Mariette C, Chevalier D, Amrouni H (2001). "Surgical management of carcinoma of the hypopharynx and cervical esophagus: analysis of 209 cases". Arch Surg. 136 (10): 1164–70. PMID 11585510.
- ↑ 3.0 3.1 Deschamps C, Nichols FC, Cassivi SD; et al. (2005). "Long-term function and quality of life after esophageal resection for cancer and Barrett's". Surgical Clinics of North America. 85 (3): 649–656. PMID 15927658.
- ↑ Affleck DG, Karwande SV, Bull DA, Haller JR, Stringham JC, Davis RK (2000). "Functional outcome and survival after pharyngolaryngoesophagectomy for cancer". Am. J. Surg. 180 (6): 546–50. PMID 11182415.
- ↑ "Esophageal Cancer Treatment".
- ↑ Haddad NG, Fleischer DE (1994). "Endoscopic laser therapy for esophageal cancer". Gastrointest. Endosc. Clin. N. Am. 4 (4): 863–74. PMID 7529119.
- ↑ Mellow MH, Pinkas H (1985). "Endoscopic laser therapy for malignancies affecting the esophagus and gastroesophageal junction. Analysis of technical and functional efficacy". Arch. Intern. Med. 145 (8): 1443–6. PMID 4026476.
- ↑ Emami B, Lyman J, Brown A, Coia L, Goitein M, Munzenrider JE, Shank B, Solin LJ, Wesson M (1991). "Tolerance of normal tissue to therapeutic irradiation". Int. J. Radiat. Oncol. Biol. Phys. 21 (1): 109–22. PMID 2032882.
- ↑ SEAMAN WB, ACKERMAN LV (1957). "The effect of radiation on the esophagus; a clinical and histologic study of the effects produced by the betatron". Radiology. 68 (4): 534–41. doi:10.1148/68.4.534. PMID 13432180.